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IG finds "highest levels of chaos" at DC vets' hospital

The Lowell Sun

Updated:
04/13/2017 03:03:45 PM EDT

By Aaron C. Davis

(c) 2017, The Washington Post

At the main health-care facility for veterans in the nation's capital, doctors have had to halt operating room procedures and dialysis treatments in the past year because of a lack of supplies, nurses have had to run through the facility looking for nasal oxygen tubes during an emergency, and sterile surgical items have been left in dirty or cluttered supply rooms, according to a new report.

Conditions at the Department of Veterans Affairs D.C. Medical Center were so troubling that the agency's inspector general released a rare interim report Wednesday saying he is conducting a probe of the facility but did not want to wait for its completion to warn the public.

"We have not seen anything quite like this at a VA facility," said Inspector General Michael J. Missal. "They have no inventory system. They don't know what they have or what they are going to need."

"Hospitals are typically chaotic places," he told The Washington Post, "but this was the highest levels of chaos. Staff was literally scrambling every day. Sometimes they would have to go to other hospitals to get equipment as a procedure was going on."

Missal said he also had a second motivation for going public: Investigators had determined that VA had known about some of the deficiencies for years, and therefore the inspector general had a "lack of confidence" that the agency would quickly address the problems.

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The report had an immediate impact. The VA placed the head of the medical center on leave Wednesday afternoon and brought in a senior agency official and additional staff.

"The department considers this an urgent patient-safety issue," the agency said in a statement. "VA is conducting a swift and comprehensive review into these findings. VA's top priority is to ensure that no patient has been harmed. If appropriate, additional disciplinary actions will be taken in accordance with the law."

The Washington DC VA Medical Center provides care to almost 100,000 veterans from across the region. The investigation into problems at the facility began in March with a tip from a confidential informant, according to the inspector general's report. Most of the problems investigators subsequently found centered on inadequate staffing and scant attention to medical supplies.

The medical center has a 100,000-square-foot storage facility and 25 satellite storage areas containing an estimated $150 million in medical supplies, but staff members have not inventoried materials in more than a year and therefore cannot find items when needed, the report said. In some instances, the facility can't verify whether doctors are using products that may have been recalled or that have expired.

A lease on the central facility is set to expire in less than three weeks, and VA appears to have made no provisions for relocating supplies. At 18 of the satellite areas, the report said, VA was also storing surgical instruments and other items in dirty or cluttered rooms.

The logistics failures routinely affected patient care, inspectors found. Last month, the medical center ran out of bloodlines for dialysis treatment and could only perform the procedure by borrowing supplies from a private hospital.

On March 29, a nurse wrote in an email that during an acute episode with a patient, she could not find tubes in her unit's storage area to insert into a patient's nose to provide oxygen.

On April 10, the operating room staff had to halt vascular surgeries because it had run out of patches used during the procedures, despite having requested a resupply two weeks earlier.

Also this week, the inspector general's office learned that other surgical operations were ongoing even though the hospital had run out of compression devices to place on patients' legs to prevent blood clots from forming.

The interim report identified almost 200 instances in which equipment shortages may have affected patient safety.

The medical center's website lists Brian Hawkins as its medical director. Without naming Hawkins, VA said in a statement that the head of the facility had been placed on administrative leave.

The inspector general's report also said several senior positions below medical director, including a chief of logistics, a head nurse and other top slots, had remained vacant, in some cases for years.

"Many VA medical centers have a really hard time hiring, but this seems worse than the others," Missal said.

VA has temporarily moved human resources responsibilities for hiring for the D.C. medical center to its Baltimore medical center.

Missal said a focus of his investigation will be determining how the situation was allowed to deteriorate and remain that way.

"We are going to be exploring who knew what and who had the power to do something about this," he said.

The inspector general may not be the only one investigating. Rep. Tim Walz (Minn.), the ranking Democrat on the House Veterans' Affairs Committee, called on his committee to do the same.

"The details documented in this report regarding serious patient safety issues at the Washington, D.C., VA are outrageous and unacceptable," Walz said. "When you have systemic failure on this level, management must be held accountable. The House Veterans' Affairs Committee must conduct oversight on this critical issue without delay."

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